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[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s] He may have been in his second decade of life.
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]
I'm never going to miss this one!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.

Please add any other signs or symptoms that may aid iin this DX..

Click to expand...

Guarding, too. Patient preferred to sit up rather than lie flat down.

Sadly, the guy's appendix was perfectly normal when removed... and the pain continued well afterward. I have no idea what happened to him, to this day.

- Pain is most often very severe
- Touching the localized area will cause greater pain
- Patient increases much greater pain when asked to raise their right leg (while laying down) against slight resistance

A patient with a score of 0 to 3 could be considered to have a low risk of appendicitis and would be discharged with advice to return if there was no improvement in symptoms, subject to social circumstances.

A patient with a score of 4 to 6 would be admitted for observation and re-examination. If the score remains the same after 12 hours, operative intervention is recommended.

A male patient with a score of 7 to 9 would proceed to appendectomy.

In validation studies, the Alvarado score had a sensitivity of 95 percent for appendicitis with a score greater than 7 and overall accuracy of 83 percent.

I don't know anything about lawsuits, but the two examples are different.

In one case, the baby needs to come out, rather that be vaginally or via C-section. The appendix didn't need to come out.

Click to expand...

Ehh most medical lawsuits are for a permanent disability in some way, shape or form.

Assuming the surgery didn't cause complications there isn't much of a lawsuit on a 3 inch long scar and no permanent problems. Is an attorney really going to spend tens of thousands of dollars for a scar and the patient missing a week off work?

I don't know anything about lawsuits, but the two examples are different.

In one case, the baby needs to come out, rather that be vaginally or via C-section. The appendix didn't need to come out.

Click to expand...

it's kind of the same. both can present emergently and have very concerning history but benign or ambiguous physical exam, then what do you do? in this scenario, you dont have access to an US or CT. do you then send home or prophylactically cut?

you get sued for waiting and delivering a dead child or rupturing an appy

you still talk to the patients and most are very reasonable and understand the consequences and most of the time will trust you

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.

Please add any other signs or symptoms that may aid iin this DX..

Click to expand...

How do people feel about this one? I feel pt's with ruptures look terrible, but I feel I have seen a good amount of mild cases where the pt looks pretty well.

From experience, and not using the scale, A patient with a high a Alvarado score comes in rarely. Majority of appy's are in the 3-5 range, that I've seen.
I'm a little surprised that migratory pain is scored the same as the other symptoms on that scale.. Migratory pain is the strongest clinical symptom of appy (highest likelihood ratio).

My institution is very imaging happy, and I've only got a surgeon to take two appy's to the OR without imaging. Both male teenagers.

From experience, and not using the scale, A patient with a high a Alvarado score comes in rarely. Majority of appy's are in the 3-5 range, that I've seen.
I'm a little surprised that migratory pain is scored the same as the other symptoms on that scale.. Migratory pain is the strongest clinical symptom of appy (highest likelihood ratio).

My institution is very imaging happy, and I've only got a surgeon to take two appy's to the OR without imaging. Both male teenagers.

Click to expand...

Well migratory pain is only found in around 50% of the cases, so giving it a higher score could lead to underdiagnosing patients.

range [IQR]: 8.5, 14.9 yr); 36% of patients were diagnosed with appendicitis. Among patients with appen-
dicitis, the most common atypical features included absence of pyrexia (83%), absence of Rovsings sign
(68%), normal or increased bowel sounds (64%), absence of rebound pain (52%), lack of migration of
pain (50%), lack of guarding (47%), abrupt onset of pain (45%), lack of anorexia (40%), absence of maximal
pain in the right lower quadrant (32%), and absence of percussive tenderness (31%).

truth is the number of negative laps over the past 50 years means almost everyone w/ suspected appy gets worked up, and usually a CT. and that's how it should be.

For reasons already mentioned, mere physical exam presentation is not acceptable for determining the urgency of sx in suspected appy. A young patient w/ impending perf/peritonitis can appear very well and suddenly crash. There are classic signs, with sens/spec in the 60-70%, however this isn't good enough. Even in the presence of increased WBCs, surgical abdomen, classic history, fever, +psoas, young patient, etc most of the time surgeons will request CT confirmation, or less often be satisfied w/ U/S (which is quick, painless, cheap and in some patients diagnostic). And imo that's how it should be, to avoid negative laparoscopy.

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s]I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Click to expand...

Only if you don't see very many patients with it.

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Click to expand...

I rarely see a fever, and the pain should start periumbilical, not epigastric.

From experience, and not using the scale, A patient with a high a Alvarado score comes in rarely. Majority of appy's are in the 3-5 range, that I've seen.
I'm a little surprised that migratory pain is scored the same as the other symptoms on that scale.. Migratory pain is the strongest clinical symptom of appy (highest likelihood ratio).

My institution is very imaging happy, and I've only got a surgeon to take two appy's to the OR without imaging. Both male teenagers.

Click to expand...

Most of my appies are at least a 6. We don't typically take a girl to the OR just on history and physical, but we'll take a younger guy to the OR fairly frequently.

Thank you everyone for the quick responses especially The Prowler and the Lawyer...

I think there were a few revelations in the thread eg.

1)The nebulousness and obscurity of the word sick.
2)The insight of the Prowler mentioning a relief of pressure for a while with the perforated viscous. /Also the rare fever.
3)Alvarado score
4)Annoying atypical presentations.
5)Numerous hands on maneuvers.
6)SouthernIM gave a definition for that word sick.
7)I'm glad no one ran beserk with a CT scan..

When the viscus perforates, the patient often feels a lot better for a little while, just like when they dehisce. Relieves the pressure.

Click to expand...

ive seen this once. guy perforated possibly a 1 week prior, got better then got super sick. then he came in, we ex lap'ed and his abdomen was all stool. i dont know what happened next as i switched service.

not all get as bad as that guy. some will perforate and the body will just wall it off but why take the chance, just get it out early

ive seen this once. guy perforated possibly a 1 week prior, got better then got super sick. then he came in, we ex lap'ed and his abdomen was all stool. i dont know what happened next as i switched service.

not all get as bad as that guy. some will perforate and the body will just wall it off but why take the chance, just get it out early

Click to expand...

Thats a good point also: The greater omentum or lesser omentum could just wall it off!

ive seen this once. guy perforated possibly a 1 week prior, got better then got super sick. then he came in, we ex lap'ed and his abdomen was all stool. i dont know what happened next as i switched service.

not all get as bad as that guy. some will perforate and the body will just wall it off but why take the chance, just get it out early

Click to expand...

I don't know the numbers, because we try not to let healthy people sit around with appendicitis, but I have to imagine that an otherwise healthy person can wall off a ruptured appendix more often than not with the omentum or small bowel.

[My fathers brother died of this in the E.R. waiting room probably around the late 1930's or 40s] He may have been in his second decade of life.
I'm never going to miss this one!! And Im going to approach it in a very Oslerian/Halstead type manner!!

Ill start, of course:

1)Pain starting at the epigastrium eventually getting to McBurneys Point..
2)Fever and only slight WBC elevation
3) Most likely patient will look sick!
4) If he or she wants to eat its not suppose to be appendicitis!!
5)Also Psoas,Obturator and Rosvings signs..

Just to add some levity and briefly. PID, ovarian torsion and mesenteric adenitis could be in the DD.

Thank you in advance.

Please add any other signs or symptoms that may aid iin this DX..

Click to expand...

Uh.........

Let me see if I can help:

RLQ pain for less than 48 hours
Objective RLQ tenderness
Never been seen in the ER before for abdominal pain
Less than 3 prescriptions for narcotics in the last year
No urinary symptoms.
Low squirrel factor

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